Principles of Surgical Oncology

Dr.Asem Qandah
Supervised By

Prof.Rami Yaghan

Oncology
Study of new growths (tumor / neoplasm) 2 types Benign Malignant

1. Benign tumors
Non-invasive growth Hyperplasia / hypertrophy No metaplastic changes Encapsulated tumors Well circumscribed Soft to firm in consistency Movable Does not metastasize

1. Benign Tumor

2. Malignant Tumor
Invasive growth Un-encapsulated Fixed Irregular border Metastasize

 Cancer is a group of diseases with different manifestations , whose common characteristic is disordered cell growth and regulation; by definition, these tumors can metastasize

Cancer is second only to heart disease as a cause of death

Recent advances in the understanding of cancer biology have facilitated the approach to the cancer patient. Following a diagnosis, the goal is to establish the extent of the disease (staging). Treatment of cancer is based on four modalities: operation, chemotherapy, radiotherapy, and immunotherapy.

DIAGNOSIS
starts with a carefully taken history and a thorough physical examination. Most symptomatic patients present with complaints of a palpable mass, cough, weight loss, bleeding, or gastrointestinal symptoms. Fewer cases are identified at an asymptomatic stage as a result of screening practices such as an abnormal mammogram, abnormal uterine cervical cytology, positive blood in stool, abnormal colonoscopy, or an enlarged prostate.

Clinical Manifestation Nine Classic Symptoms / Signs

1. 2. 3. 4. 5. 6. 7. 8. 9. Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or a lump anywhere in the body Indigestion or difficulty of swallowing Obvious change in warts or moles Nagging cough or hoarseness Unexplained anemia Sudden unexplained weight loss

Clinical Manifestation
Cancer warning signals: CAUTION US

Other manifestation
1. 2. 3. 4. 5. 6. 7. 8. 9. Anorexia / Cachexia Obstruction Neurologic deficit / neuropathy Pleural effusion / ascitis Growth into surrounding structures pain, fixation, etc Electrolyte disturbance hormone secreting tumors Thromboembolism Systemic manifestation hormone secreting tumors Metastasis occult tumors

Diagnosis
1. 2. History and Physical Examination Laboratory Examination a. Tumor marker
I. II. III. Non-specific Not ideal for cancer screening Ideal for monitoring i. Response to treatment ii. Tumor recurrence

Tumor Markers

Type

Marker

1. Prostate Prostate Specific Antigen (PSA) 2. Colon Carcinoembryonic Antigen (CEA) 3. Liver Alpha-fetoprotein (AFP) 4. Breast CA 15-3 5. Pancreas CA 19-9 6. Ovary CA 125 7. Thyroid Thyroglobulin 8. Medullary CA Calcitonin 9. Germ cell tumor Beta-HCG

Diagnosis
3. Radiologic Imaging
a. b. c. d. e. f. g. Chest X-ray Ultrasonography CT Scan Magnetic Resonance Imaging Bone Scan Mammography Positron Emission Tomography Esophagogastroduodenoscopy Colonoscopy Bronchoscopy Nasopharyngolaryngoscopy Cystoscopy

4.

Endoscopy
a. b. c. d. e.

DIAGNOSIS
A diagnosis of cancer should be substantiated with a pathologic diagnosis. Careful attention should be devoted to the planning and performance of the biopsy procedure.

DIAGNOSIS
Any time a tissue sample is obtained, the incision or needle tract is considered contaminated and should be placed in an area that will be subjected to cancer treatment to eliminate any potential seeding of cancer cells.

Diagnosis 5. Biopsy
Confirmatory examination Histopathologic result Types of Biopsy
I. II. III. IV. Fine needle aspiration Core needle Excision Incision

DIAGNOSIS
1. Fine needle aspiration cytology percutaneously, a skinny needle is introduced in the tumor; with gentle suction, fragments of tissue, but mostly cells, are aspirated into the hub of the needle.

1. Fine Needle Aspiration

Least invasive Painless, rapid Convenient office procedure Study cellular characteristics of malignancy Operator and Cytopathologist dependent Histologic confirmation obtained after surgery Results True positive rate: 75 96% False positive rate: rare False negative rate: 3 15% NOT applicable for sarcomas and melanomas

 2. Core needle biopsy (tru-cut biopsy)is equivalent to an incisional biopsy; percutaneously, with a special large bore needle, a fragment of tissue is obtained. There is risk of bleeding and spread of cancer cells through tissue planes. This technique is most helpful in large tumors to avoid poor healing of an incisional biopsy.

2.

Core Needle
Use 14 gauge needle (TRU-CUT, Vim-Silverman) Obtain a core of solid tissue for histopathologic examination Study cellular and architectural features of tumor Ideal for diagnosis of sarcomas, mesenchymal tumors Logical next step for FNA that are non-diagnostic or unsatisfactory May result to: Bleeding or hematoma formation at site of puncture May perforate visceral organs and lungs

 3. Incisional biopsyan incision is placed over the tumor and a portion of the tumor is excised. It is often the preferred modality in larger tumors for which histological diagnosis directs subsequent treatment. It provides a large specimen, but there is risk of bleeding and breakdown of the suture line by tumor or infection.

3. Incisional biopsy
Used if lesion is more than 4 cm diameter Done so as not to compromise definitive surgery if needed

 4. Excisional biopsyconsists of excision of the tumor mass. It should only be done when the mass is small and further resection of adjacent tissue, if needed for definitive treatment, will not be compromised.

4. Excisional biopsy
Complete removal of tumor Ideal for lesions less than 4 cm diameter Done if FNA & Core needle biopsy result is uncertain

 Principles of biopsy A number of very important principles should be followed when collecting a biopsy. These include : 1.choosing a biopsy site that can be later resected. 2.a longitudinal rather than a transverse incision on the limbs 3.avoiding tumor seeding. 4.avoiding areas of ulceration, necrosis or inflammation. 5.orienting the biopsy in the direction of the definitive surgical resection. 6.obtaining specimens from >1 region of the tumor. 7.avoiding electrocautery. 8.handling the specimen carefully to avoid tissue deformation. 10.prompt and appropriate fixation (10 parts formalin:1 part tissue). 11. a detailed history with the report, and providing multiple samples if possible.

STAGING
Staging is a system to define the extent of disease in a standardized fashion. It is a consequence of our understanding of the biology of cancer. Adequate classification and staging help determine treatment, evaluate therapeutic results, and compare results of different modalities from different institutions more reliably.

STAGING
Staging should start with a careful history and physical examination. Selective use of laboratory tests, like alkaline phosphatase for tumors that metastasize to liver or bone and carcinoembryonic antigen for colon cancer, are helpful. Radiographic studies should include a chest x-ray. Computed tomography (CT) scanning, magnetic resonance imaging (MRI), and radioisotope studies should be ordered judiciously and in a cost-effective manner.

STAGING
TNM system
Based on anatomical extent of spread

-T refers to the extent of primary tumor

-N refers to the extent of nodal metastases -M refers to the presence or absence of distant metastases

TNM system
T - primary tumor Tx primary tumor can not be assessed To no evidence of primary tumor Tis carcinoma in-situ T1-4 increasing size and local extent of primary tumor

TNM system
N - regional lymph nodes Nx regional lymph nodes can not be assessed N0 no regional lymph node metastases N1-3 increasing involvement of regional lymph nodes M - distant metastases Mx distant metastases can not be assessed M0 no distant metastases M1 distant metastases present

 Synchronous cancer : if it is diagnosed within 6 months of the primary diagnosis. This finding is often significant because it may prompt a change in treatment, such as mastectomy instead of breast preservation. Synchronous cancers occur in about 5% of patients with colon cancer; therefore, preoperative colonoscopy is recommended.

TREATMENT
The treatment of the cancer patient should be individualized. The modality is selected according to the tumor histogenesis, the organ of origin, and the extent of disease. Often, multimodality treatment, including operation, chemotherapy, radiotherapy and, more recently, immunotherapy is required.

 The benefits of surgery compared to other treatment modalities include the fact that it is non-carcinogenic, less immunosuppressive and offers the best chance of local cure. Disadvantages of surgery compared to other treatment modalities include the morbidity and mortality associated with the procedure, the potential for decreased function and possible disfigurement.

TREATMENT
An important question in planning therapy is to define whether the patient has known metastatic disease, or is at high risk of having metastases that are not large enough to be detected by physical examination or radiologic studies. Patients physiologic status and wishes are also important in treatment selection.

TREATMENT
Surgery and radiotherapy are modalities of treatment of local disease. Historically, operation was the first mode of therapy to be effective in the treatment of cancer. Unfortunately, approximately 70% of patients will fail surgical therapy alone, mostly due to systemic metastases.

TREATMENT
The surgeon must define the role of the surgical procedure in the care of the individual patient: 1. Surgery for diagnosis 2. Surgery for staging Pathologic confirmation provides more accurate assessment of the extent of locoregional disease than physical examination alone. Surgical staging is similarly considered the gold standard following laparotomy in patients with gastrointestinal malignancies.

TREATMENT
3. Surgery for curefailure to resect all locoregional disease will result in failure to cure. An oncologic en-bloc resection should encompass the primary tumor with clear margins (grossly and microscopically), including adjacent organs (if necessary), the regional lymphatics, and the biopsy site. 4. Surgery for debulking it is limited and only reserved for selected malignancies, to reduce the tumor burden . It is essential that other modalities are effective in controlling the residual disease (e.g., ovarian cancer).

5. Surgery for palliation surgery is often necessary to relieve symptoms even when resection for cure is not feasible. For example, when a patient with colon cancer is found to have non resectable liver metastases, segmental resection of the colon may be beneficial in the control of pain, bleeding, and/or obstructive symptoms. 6. Surgery for prophylaxis the field of primary prevention originated from our ability to identify individuals at high risk of developing disease (in this case, to develop cancer). An example is prophylactic colectomy in persons with familial polyposis

 Radiotherapy is also a local modality of treatment. Its efficacy is dependent on the relative radiosensitivity of the tumor. When effective, it has the advantage of destroying tumors with preservation of function and form. It can be used as a primary modality of therapy as in Hodgkins disease. As an adjuvant modality, it may limit the extent of necessary surgical resection, with preservation of a limb as in the case of sarcoma or with preservation of the breast as in mammary cancer. Palliative radiotherapy is used to control symptoms from metastases or a primary tumor.

 Chemotherapy is the treatment of cancer with drugs. When drugs are used as the primary modality of treatment, it is called induction chemotherapy. Chemotherapy has been used as an adjuvant modality (to attack metastases at a microscopic state) with some success in patients with breast cancer and in selected patients with colon cancer. No benefit of adjuvant chemotherapy has been noted in other malignancies (gastric, pancreatic carcinoma, sarcomas). Neoadjuvant or primary chemotherapy entails the use of anticancer drugs before surgery for a solid tumor.

FOLLOW-UP
Close follow-up is necessary in the care of cancer patients. The surgical oncologist must be willing to listen, be compassionate, and communicate with the patient, being realistic but always providing emotional support to the patient and relatives. Follow-up of the cancer patient should also emphasize rehabilitation after surgery (amputation,mastectomy) and return to a productive life.

FOLLOW-UP
Evaluation for follow-up must address the following questions: 1. Was the patient potentially cured? 2. Is there a locoregional recurrence? 3. Is there evidence of metastases? 4. Is there a metachronous lesion? 5. Is the patient at risk of other cancers? The answers are provided after a carefully taken history and physical examination, and selective use of laboratory and radiologic examination. Specific tests may be required to detect metachronous lesions (colonoscopy, mammography).

Calculation of a Surgical dose

The surgical dose can be an intracapsular resection (debulking in which a microscopic quantity of tumour remains), a marginal resection (just outside tumour's pseudocapsule, microscopic quantity of tumour remains), a wide resection (complete excision with all margins free of tumour cells) or a radical resection (remove entirety of a body part). A wide local resection is the most common surgical dose with the width of margins of excision determined on the basis of tumor type, aggressiveness, anatomic location and the barrier provided by surrounding tissue.

Surgical dose
The margins are three dimensional- lateral, medial and deep. Consideration should also be given to the quality of the margin rather than just the quantity. This is most important when considering the deep margin. Collagen dense, vascular poor tissue such as cartilage, tendons, ligaments, fascia are resistant to neoplastic invasion whereas fat, subcutaneous tissue, muscle, and parenchymal tissue are not resistant.

Surgical dose
The aim of resection is to achieve a cuff of normal tissue surrounding the tumor and one additional tissue plane beyond that which the tumor touches. Wound closure should be preplanned and a variety of wound closure techniques should be considered to avoid influencing the resection by concerns about the ability to close the deficit.

THANK YOU

A 44-year-old female presented with a 4-month history of a progressively enlarging mass in the right breast. She denied any nipple discharge or pain. Her older sister died of breast cancer at 46 years of age; her younger sister is alive with bilateral breast cancer; her mother also died of breast cancer. Her last mammogram was 18 months ago.
She appeared in good health. On physical examination, there was a 2- by 2-cm mass in the upper outer quadrant of the right breast. There were no skin changes. Examination of the opposite breast, both axillae, and the supraclavicular fossa was normal. Blood counts and liver chemistries were normal. Chest x-ray was unremarkable. Bilateral mammography showed a spiculated mass corresponding to the palpable mass and a separate cluster of microcalcifications in the lower inner quadrant of the right breast.

BREAST CANCER

Fine needle aspiration cytology study of the palpable mass adenocarcinoma cells. She had an excisional biopsy of the mammographically localized area of microcalcifications that revealed infiltrating ductal carcinoma. A modified radical mastectomy of the right breast was performed. No residual carcinoma was found in the area of the excisional biopsy. Of 30 axillary lymph nodes, 3 were positive for carcinoma. She received adjuvant chemotherapy and is currently doing well 5 years after surgery. She is taking tamoxifen and has no evidence of recurrence. She has had yearly mammograms without any evidence of a tumor in the opposite breast.

SOFT TISSUE MASS

A 48-year-old Hispanic female presented with a 16month history of a progressively enlarging mass over the sacrum. One year ago, an incisional biopsy revealed fibroadipose tissue. She was told that she had a lipoma and not to worry. Her prior medical history and family history were unremarkable.

On examination, she had a 8 8-cm mass located over the sacrum. This was hard, but not fixed to the underlying bone. An MRI of the sacrum and pelvis was obtained, revealing a mass of high attenuation separate from the bone, consistent with a soft tissue tumor, not consistent with fatty tissue. Core needle biopsy showed sarcoma.

A subperiosteal resection and wide excision of the tumor with adjacent normal tissue was done. The surgical margins were free of tumor. The wound was closed with advancement flaps and drains were placed. Final pathology confirmed the original diagnosis with a close deep margin at 0.8 cm. She has subsequently received radiotherapy to the tumor bed and drain sites. She was doing well 3 years postoperatively without any evidence of recurrence.